"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

February 14, 2018

The next large-scale infectious disease outbreak would not just be a public health crisis but also an economic crisis for the United States, in the shape of jobs lost and a draining of the export economy—even if it were to happen halfway around the world—according to two studies from the Centers for Disease Control and Prevention (CDC) published in Health Security.

The papers follow the unveiling of President Donald Trump's fiscal year 2019 budget, which includes $59 million to support the Global Health Security Agenda (GHSA). The acting director of the CDC, Anne Schuchat, MD, said these funds were vital to the country's economic security.

"The President's Budget request of $59 million for Fiscal Year 2019 for GHSA demonstrates the Administration’s commitment to global health security and provides an important bridge to the extension of the GHSA announced in October 2017 in Uganda," said Schuchat, in a press release. "This new funding continues the U.S. commitment to this multi-national effort and supplements U.S. Government multisector support for this initiative."

The GHSA, however, currently receives $180 million a year, so Trump's budget, if enacted, would result in a major cut. Time will tell which of Trump's budget recommendations will pass Congress.

Threats to the export economy

The first article, "Relevance of Global Health Security to the US Export Economy" presumes a major infectious disease outbreak takes place in 1 of the CDC's 49 global health security priority countries, which include trade partners such as India and South Africa.

Though the 2014-2016 West African Ebola outbreak illustrated how quickly pathogens can cross borders, even an outbreak that stays contained in a country or region could wreak havoc on the US trade economy, the authors said. According to their research, US exports to the 49 countries were $308 billion in 2015 and supported more than 1.6 million American jobs in agriculture, manufacturing, mining, oil and gas, services, and other sectors. That's 13.7% of all US export revenue worldwide, and 14.3% of all US jobs supported by all US exports.

The researchers found that all 50 states have jobs related to the export economy that would be lost in the face of an epidemic, but certain states are more heavily involved in the exporting economy: California, Texas, and Washington were the largest exporters of manufactured goods to the priority countries, with each exporting more than $21.5 billion.

Continued investment in global capacities could help stave off these losses, the authors said in the article, which was published in December.

During our last two infectious-disease crises — the Ebola epidemic in 2014 and the Zika outbreak in 2015 and 2016 — Donald Trump’s xenophobic, divisive and antiscience instincts were on display to horrible effect. As Obama mustered a response to Ebola in West Africa — to save lives and to contain the disease — Trump repeatedly tweeted that the United States should cut off overseas response efforts, decline treatment to an American evangelical doctor who had contracted the disease, and reject standard scientific protocols.

During the Zika outbreak, an apathetic Trump backed anti-immigrant lawmakers who delayed funding for a federal response — leading to the first-ever cases of the disease being contracted in the United States. And after Trump’s election, he met with antivaccine activists — building on a history of tweets that baselessly tied autism to vaccination rates.

While President Trump’s key early appointees in this area — Health and Human Services Secretary Tom Price and CDC director Brenda Fitzgerald — departed from the president’s worst instincts on pandemic prevention, both were felled by ethical issues. Trump himself has been mum on the flu; it appears to be the one of the few topics in public life on which he has nothing to say. America will get through this year’s epidemic without him, but what about the major threat that looms on the horizon: a deadly pandemic flu? Here, Trump’s terrible instincts and attitudes could be catastrophic.

How bad could such a pandemic be? 2018 marks the 100th anniversary of the 1918 Spanish flu, which killed more than 600,000 Americans — more than World Wars I and II combined. Doctors today have more tools to combat such an outbreak, but our increased interconnectedness means we face a greater threat of rapid spread than we did a century ago. As a result, modern science will do less to protect us from a flu pandemic than most people suspect.

Our best defense against such a pandemic reaching our shores is an investment in global health security: stopping diseases overseas. But the Trump administration has undertaken a stunning reversal of 16 years of progress under President George W. Bush and Obama. The massive government funding bill approved in mid-February slashed funds for the CDC’s Prevention and Public Health Fund.

Team Trump recently announced deep cuts to global health funding rooted in the Ebola epidemic, implementing an 80 percent reduction in the global reach to detect infectious-disease outbreaks abroad. Trump’s newly released budget proposal would wreak more havoc by cutting another $1 billion from the CDC.

Such an “America First” mind-set toward health security is dangerous. Disengaging from the world not only turns our back on humanitarian needs abroad — it also increases the risk that those crises will reach our shores. Because of rapid international travel, an outbreak in a remote village in China or a forest in Africa can lead to disease transmission in a U.S. urban center within 24 hours, and in any town in our country hours later. Before we even know the threat has arrived, our emergency rooms could be overwhelmed. And no, MAGA Nation, a giant wall along our southern border will not protect us.

February 09, 2018

A news release from UOSSM, the Union of Medical Care and Relief Organizations:

A four day surge in violence has left 237 dead and 1250 injured in Eastern Ghouta. Seven medical facilities have also been attacked throughout Syria, leaving thousands with scarce access to medical care when it is needed most.

On February 8 at 9:50 am Damascus time, the Mishmeshan Primary Health Center in Idlib was attacked, destroying it completely, and putting it out of service. Six were killed. Four medical staff and four Syrian Civil Defense paramedics (White Helmets) were injured along with several others that were on premises at the time of the attack.

On February 8 at 8 p.m. Damascus time, the Al Rahma Hospital in Khan Sheikhoun was attacked and put out of service. The hospital was completely destroyed. One of the medical staff was killed and several others were injured.

On February 8, The Syrian Civil Defense (White Helmets) center in Khan Sheikhoun was attacked killing three members of the White Helmets, and wounding four others.

On February 7, the obstetrics hospital in Douma, Eastern Ghouta was targeted by airstrikes causing severe damage and the death of an administrative worker.

On February 6 at 11 a.m. Damascus time, the ‘Save a Soul’ Mental Health Center in Easten Ghouta was hit by several missiles. At around the same time a ‘Save a Soul’ Primary Health Care Center was also attacked. Two staff and two patients were wounded. The center provided healthcare for 20,400 patients.

On February 6, a dental clinic in ‘Albaraa center’ of Eastern Ghouta was targeted and destroyed.

There have been at least 35 attacks on medical facilities and staff in 2018, leaving thousands in a vulnerable state with little or no access to medical care. Many of the attacks are within the ‘de-escalation zone’ and have large populations of IDPs who are extremely vulnerable already.

"I am sickened by the relentless attacks against civilians and deliberate targeting of hospitals. How can they justify killing 237 civilians and injuring over 1,250 civilians in the past four days? Our hospitals and medical facilities are being hit by surgical strikes. The injured have nowhere to turn and are dying in the streets and their homes. The reckless bombing of civilians we are seeing amounts to a war crime, and must be stopped. Civilians are not targets. Hospitals are not targets,” said Dr. Ghanem Tayara, Chairman of UOSSM International and Birmingham, UK GP.

Four years after the United States pledged to help the world fight infectious-disease epidemics such as Ebola, the Centers for Disease Control and Prevention is dramatically downsizing its epidemic prevention activities in 39 out of 49 countries because money is running out, U.S. government officials said.

The CDC programs, part of a global health security initiative, train front-line workers in outbreak detection and work to strengthen laboratory and emergency response systems in countries where disease risks are greatest. The goal is to stop future outbreaks at their source.

Most of the funding comes from a one-time, five-year emergency package that Congress approved to respond to the 2014 Ebola epidemic in West Africa. About $600 million was awarded to the CDC to help countries prevent infectious-disease threats from becoming epidemics. That money is slated to run out by September 2019. Despite statements from President Trump and senior administration officials affirming the importance of controlling outbreaks, officials and global infectious-disease experts are not anticipating that the administration will budget additional resources.

Two weeks ago, the CDC began notifying staffers and officials abroad about its plan to downsize these activities, because officials assume there will be “no new resources,” said a senior government official speaking on the condition of anonymity to discuss budget matters.

Notice is being given now to CDC country directors “as the very first phase of a transition,” the official said. There is a need for “forward planning,” the official said, to accommodate longer advance notice for staffers and for leases and property agreements. The downsizing decision was first reported by the Wall Street Journal.

The CDC plans to narrow its focus to 10 “priority countries,” starting in October 2019, the official said. They are India, Thailand and Vietnam in Asia; Jordan in the Middle East; Kenya, Uganda, Liberia, Nigeria and Senegal in Africa; and Guatemala in Central America.

Countries where the CDC is planning to scale back include some of the world’s hot spots for emerging infectious disease, such as China, Pakistan, Haiti, Rwanda and Congo. Last year, when Congo experienced a potentially deadly Ebola outbreak in a remote, forested area, CDC-trained disease detectives and rapid responders helped contain it quickly.

In Congo's capital of Kinshasa, an emergency operations center established last year with CDC funding is operational but still needs staffers to be trained and protocols and systems to be put in place so data can be collected accurately from across the country, said Carolyn Reynolds, a vice president at PATH, a global health technology nonprofit group that helped the Congolese set up the center.

If there's any consolation here, it's that other countries, NGOs, and WHO, doing what they can to take up the slack, will be able to snap up a lot of American healthcare experts whose CDC careers are now over.

Heavy street fighting and renewed airstrikes since 29 November have paralysed the capital, Sana’a, with civilians trapped in their homes for several days, and have left the injured without safe access to medical assistance. Medical teams using ambulances to try and retrieve the injured have reportedly come under fire. Hundreds of people are said to have been killed. Although MSF has not received the necessary guarantees from parties to the conflict to move inside Sana’a, it has been able to make medical donations to hospitals in the city.

Clashes have spread to other parts of the country, such as Hajjah, Amran and Ibb governorates. On 2 December, MSF received 28 war-wounded patients at its two hospitals in Khamer and Houth, in the northwest of the country. In the early hours of 4 December, an airstrike damaged the MSF-supported Al Gamhouri hospital in Hajjah city. The emergency room, operating theatre and intensive care unit were damaged and 12 ER patients were evacuated. Despite the damage, Al Gamhouri hospital received 22 casualties from the airstrikes in Hajjah shortly after. Al Gamhouri also received a total of 38 war-wounded patients between 2 and 3 December.

“Health services have been repeatedly attacked over the course of this conflict. Yet again warring parties are not taking measures to spare medical facilities, endangering the lives of patients and medical staff,” says Steve Purbrick, MSF Field Coordinator in Hajjah. “Civilians must be able to flee or seek medical care, ambulances must be allowed to reach the injured and hospitals must be protected.”

November 27, 2017

BRUSSELS/NEW YORK, NOVEMBER 27, 2017—Hundreds of people have been wounded in intense bombing and shelling in the besieged East Ghouta enclave near Damascus, Syria, in the last two weeks, creating a disaster for patients in need of medical treatment, the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) said today.

MSF, which does not have its own medical staff in East Ghouta, provides support to field hospitals and clinics serving the local population. From November 14 to 26, five MSF-supported field hospitals in East Ghouta treated 576 wounded patients and recorded 69 deaths. This includes patients from 24 mass casualty influxes to these facilities. About a quarter of the wounded and the dead are women or children under 15 years old.

These figures do not account for the total numbers of people killed and wounded in East Ghouta as there are other facilities in the area that MSF does not regularly support.

"During this period of intense conflict, medical care is urgently needed for men, women, and children," said Bertrand Perrochet, MSF director of operations. "But the services in East Ghouta are stretched beyond their limits. Even those who risk trying to reach a hospital or clinic may find that it has reduced services due to the fear of bombing, and many facilities are consuming exceptional amounts of medical supplies that will be difficult to replenish."

The availability of medical care in East Ghouta has declined due to bombing, shelling, and fear of attacks. A major field hospital in Kafr Batna, East Ghouta, that MSF has been supporting from abroad since 2013, was hit on November 20 by two rockets, destroying a water tank and solar panels, causing some damage to the in-patient department, and putting one ambulance out of service. Fortunately, there were no serious injuries to staff or patients in this incident, but the hospital suspended its services for two days to enable essential repairs.

Another clinic and two field hospitals supported by MSF temporarily suspended their non-emergency services from November 15 to 18 out of concern for the safety of medics and patients.

MSF assists 21 medical facilities in the area with medical supplies and has built up a local reserve of medical supplies for distribution in times of critical need. These stocks are now being used rapidly, with some items nearly or completely used up, such as blood bags, dextrose IV-fluid pouches, large-size examination gloves, iodine, and oral pediatric antibiotics.

Most of the facilities MSF is in contact with report needing more supplies, not only for treating the wounded but also for treating sick patients who constitute the majority of urgent cases. If these facilities cannot obtain essential medical supplies, treatment options will further decline, putting more critical patients at risk of deterioration or death.

The pervasive fear of being hit in the near-constant bombing and shelling means people needing medical care and medical personnel are staying at home. Many patients are not getting the care they need, and medical facilities that MSF supports are increasingly short-staffed.

July 31, 2017

Of the world’s countries, only six — three rich ones and three poor ones — have taken the steps they should have to evaluate their ability to withstand a global pandemic, according to a recent report sponsored by the World Bank.

Just three wealthy countries — Finland, Saudi Arabia and the United States — have gone through two external evaluations of their readiness to face pandemics, one for human diseases and one for animal outbreaks, the study found.

As of last April, only three poor countries — Eritrea, Pakistan and Tanzania — had undergone both evaluations and had described how they planned to find the money to rectify their weaknesses.

Under Dr. Jim Yong Kim, its current president, the World Bank has strongly advocated creating emergency funds to fight disease outbreaks. In 1987, Dr. Kim helped found Partners in Health, which provides medical care in Haiti and other poor countries and which fought Ebola in West Africa in 2014.

July 22, 2017

Medecins Sans Frontiers (MSF) reopened a small medical clinic in Kunduz, Afghanistan, on Saturday, their first facility there since the American airstrikes that destroyed a hospital in 2015.

"The opening of this clinic is the first step toward providing more medical assistance in Kunduz," Silvia Dallatomasina, head of programs for MSF in Afghanistan, told Reuters. "And for us it's an important step."

Since the air attack by American special forces in 2015, which killed 42 patients, medical staff, and caregivers at the MSF trauma center, the medical aid group has been trying to secure assurances from American and Afghan military officials that their medical facilities would be respected and protected.

"We are still finalizing commitments but we believe we were able to reach an agreement," Dallatomasina said.

The new clinic in Kunduz, which is not situated at the site of the destroyed hospital, will only provide outpatient treatment of minor or chronic injuries, she said.

Patients who need more advanced care including X-rays will still need to go to the government-run regional hospital, which has been overworked amid heavy fighting in the province.

"The regional hospital is quite overwhelmed, so we want to try to reduce that burden by treating less serious injuries," Dallatomasina said.

While no final plans have been confirmed, MSF hopes to begin building a new trauma center in Kunduz as early as 2018, although likely on a smaller scale than the previous facility, she said.

The MSF trauma center was destroyed during a period in 2015 when Taliban militants briefly overran the city. An American military probe concluded that the attack was the result of human error and equipment failure, among other factors.

At least sixteen U.S. military personnel were disciplined for their role, but MSF has criticized the lack of independent investigation into the incident.

Collecting credible data on violence against health services, health workers, and patients in war zones is a massive challenge, but crucial to understanding the extent to which international humanitarian law is being breached. We describe a new system used mainly in areas of Syria with a substantial presence of armed opposition groups since November, 2015, to detect and verify attacks on health-care services and describe their effect.

Methods

All Turkey health cluster organisations with a physical presence in Syria, either through deployed and locally employed staff, were asked to participate in the Monitoring Violence against Health Care (MVH) alert network. The Turkey hub of the health cluster, a UN-activated humanitarian health coordination body, received alerts from health cluster partners via WhatsApp and an anonymised online data-entry tool. Field staff were asked to seek further information by interviewing victims and other witnesses when possible. The MVH data team triangulated alerts to identify individual events and distributed a preliminary flash update of key information (location, type of service, modality of attack, deaths, and casualties) to partners, WHO, United Nations Office for the Coordination of Humanitarian Affairs, and donors.

The team also received and entered alerts from several large non-health cluster organisations (known as external partners, who do their own information-gathering and verification processes before sharing their information). Each incident was then assessed in a stringent process of information-matching.

Attacks were deemed to be verified if they were reported by a minimum of one health cluster partner and one external partner, and the majority of the key datapoints matched. Alerts that did not meet this standard were deemed to be unverified. Results were tabulated to describe attack occurrence and impact, disaggregated where possible by age, sex, and location.

Findings

Between early November, 2015, and Dec 31 2016, 938 people were directly harmed in 402 incidents of violence against health care: 677 (72%) were wounded and 261 (28%) were killed. Most of the dead were adult males (68%), but the highest case fatality (39%) was seen in children aged younger than 5 years. 24% of attack victims were health workers. Around 44% of hospitals and 5% of all primary care clinics in mainly areas with a substantial presence of armed opposition groups experienced attacks. Aerial bombardment was the main form of attack. A third of health-care services were hit more than once. Services providing trauma care were attacked more than other services.

Interpretation

The data system used in this study addressed double-counting, reduced the effect of potentially biased self-reports, and produced credible data from anonymous information. The MVH tool could be feasibly deployed in many conflict areas. Reliable data are essential to show how far warring parties have strayed from international law protecting health care in conflict and to effectively harness legal mechanisms to discourage future perpetrators.

May 31, 2017

More than two years of conflict in Yemen have left more than 18.8 million people need some form of humanitarian assistance with 10.3 million severely in need of assistance. UNHCR reports 3 million displaced.

The health sector in Yemen is on the verge of collapse. At least 274 health facilities have been damaged or destroyed.

More than half of all health facilities in Yemen are either closed or only partially functioning. An estimated 14.8 million people now lack access to basic healthcare, including 8.8 million living in severely under-served areas, 14.5 million people lack access to clean water, sanitation and hygiene services. Since 27th April, a second outbreak of Acute Watery Diarrhoea (AWD) / Cholera cases followed a previous outbreak in September 2016. Latest information released by WASH and Health Clusters as of 27th May; indicated that: